Grading Of Preoperative Images And Surgical Risks Assessment In Patients With Meningioma

Background Meningioma originates in the arachnoid epithelial cells,and accounts for about13-26%of intracranial tumor, vast majority of which are benign tumor and common in the elderly and women.Surgery is the preferred method of treatment for meningioma, which can heal if tumor is resected completely.lt will meet all sorts of risks once having an operation, such as the risk of tumor resection incomplete, the risk of severe postoperative complications and even the risk of mortality and so on. So, is there a simple and clear meningioma grading system to judg and evaluate the prognosis of meningioma surgery? Namely different meningioma grades represent different surgical risks? As we know that in1986. Spetzler divided arteriovenous malformation into5grades, grading and scoring standard as follows:(1)size of AVM:<3cm1points,3～6cm2points,>6cm3points:(2)location of AVM:not functional areas0points, functional areas1point;(3) pattern of venous drainage: superficial vein0points, deep veinl points.Grade=size+location+venous drainage; That is Grade Ⅰ:1points; Grade Ⅱ:2points; Grade Ⅲ:3points; Grade Ⅳ:4points; Grade V:5points. And Spetzler selected all the three factors can be found from images, and this method of grading got the recognition of the medical profession at home and abroad.Whether surgeons or patients, the most concern is whether can the operation be completely resected? The risk of operation? A series of problems arise as long as mentioning meningioma. To find a simple and effective method or grading system to provide a reference or standard for later generations, many domestic and foreign scholars studied and explorated the research about meningioma grade based on so many questions. The conclusion was inconsistent and there were some controversial ideas because of different grading and classification of various influencing factors and statistical method. But in recent years, the prognosis of patients improved obviously with the development of microsurgical technique, operational skills enhancement and the development of image technology. Meningioma patients once appear to have a surgical indications, therefore, surgeons should pursue to preserve function, reduce postoperative complications and mortality rate under the premise of tumor complete resection, and to remove the base of tumor and to reach level I of Simpson. But in fact, there are many difficult factors blocking us to achieve this purpose, and these difficult factors usually can be found most directly through the preoperative image information:tumor size, location, condition of vessels and nerves wrap around, tumor aggressive, peritumoral edema, tumor shape, tumor margin and degree of enhancement and so on. In order to objectively and clearly evaluate the degree of tumor resection, surgical complications and mortality, we choose the significant factors on the basis of the analysis of difficult factors. And to judge and evaluate the prognosis of every meningioma surgery concisely before the operation, we try to put forward a grading scheme of meningioma preoperative image according to the decisive factors. Section one Correlation analysis of preoperative images and surgical outcomes in patients with meningiomaObjective To investigate meningioma preoperative images information that influences degree of tumor resection, surgical complications and mortality.Methods One hundred and seventy-two (172) patients with complete image information were retrospectively analyzed, of which57male and115female, age range from23to80years, and53years old on average, serious heart disease, pulmonary disease, hepatopathy, nephropathy or endocrine function are excluded preoperatively.Patients were performed with CT plain scan and contrast enhancement scanning, CTA and (or) conventional MRI scanning, the intravenous paramagnetic contrast agent magnevist injection (GD-DTPA) enhancement scanning (scanning parameters the same as flat T1WI), MRA, MRV, and some patients with DSA examination. Conventional MRI scanning includes the T1-weighted images (T1WI), T2weighted images (T2WI) and fluid attenuation inverse recovery (FLAIR) sequence.1. Clinical dataRecording each patient’s age, gender, preoperative clinical manifestation,image information of head CT and (or) magnetic resonance imaging, the postoperative clinical manifestation,degree of tumor resection.postoperative complications and mortality according to patients’ clinical medical records (admission record, operation notes, postoperative progress notes, preoperative and postoperative image information, laboratory results, etc.) Images information of meningioma includes tumor location, tumor size, tumor invasiveness, vessels and nerves wrap around, peritumoral edema, tumor margin, tumor shape, degree of tumor enhancement in common.2. Evaluation standard(1).Have or not complete resection or have or not residual. According to standard of grade of meningeal tumor resection Simpson proposed in1957:Grade Ⅰ: Macroscopically complete tumour removal, with excision of its dural attachment and of abnormal bone.Resection of the sinus where tumour arises from the wall of a dural venous sinus. Grade Ⅱ:Macroscopically complete tumour removal with endothermy coagulation of its dural attachment. Grade Ⅲ:Macroscopically complete tumour removal without resection of coagulation of its dural attachment or its extradural extension.Grade Ⅳ:partial tumour removal, leaving intradural tumour in situ. Simple decompression,with or without biopsy.We see Grade Ⅰ and Grade Ⅱ cases as complete resection, and see Grade Ⅲ,Grade Ⅳ and Grade Ⅴ as residual in this research.(2).With or without surgical complications. One or more complications of every patient including as follow:brain swelling,cerebral hemorrhage,hemiplegia, intracranial infection, high fever, coma, cerebral herniation, hydrocephalus, epilepsy, diabetes insipidus,subcutaneous effusion,cerebral ischemia,cerebrospinal fluid leakage,aphasia,scalp infection,cranial nerve and cerebellar dysfunction(facial paralysis.cough and hoarseness, visual disturbance,dysosmia or hearing disorder, balance disorder, etc.).(3). With or without mortality.3. Statistical analysisUsing SPSS19.0software for statistical analysis.Univariate analysis (chi-square test or Fisher test)was first performed to analyze various factors that influence degree of tumor resection,surgical complications and mortality,P<0.05for difference werestatistical significance.Then tumor with or without residue,with or without complications,with or without mortality as dependent variable respectively,factors of statistically significant as independent variable for binary Logistic stepwise regression analysis, and with P<0.1for difference were statistical significance.Results1. Results of Univariate analysis(1).Chi-square test of tumor residual,tumor location (χ2=14.139,P=0.000), tumor size (χ=17.861,P=0.000),tumor invasiveness (χ2=22.376,P=0.000), vessels and nerves wrap around (χ2=16.983,P=0.000),tumor margin (χ2=19.909,P=0.000),tumor shape (χ2=24.546,P=0.000),degree of tumor enhancement (χ2=7.201,P=0.007),peritumoral edema (χ2=1.565,P=0.221),differences of tumor location,tumor size,tumor invasiveness,vessels and nerves wrap around,tumor margin,tumor shape and degree of tumor enhancement were statistical significance (P <0.05);(2).Chi-square test of surgical complications,tumor location (χ2=16.438,P=0.000), tumor size (χ2=8.759,P=0.003),tumor invasiveness (χ2=0.3541,P=0.060),vessels and nerves wrap around (x2=14.679,P=0.000),tumor margin (χ2=3.140,P=0.076),tumor shape (χ2=11.035,P=0.001),degree of tumor enhancement (χ2=9.372,P=0.002), peritumoral edema (χ2=0.557,P=0.456),differences of tumor location,tumor size,vessels and nerves wrap around, tumor shape and degree of tumor enhancement were statistical significance (P<0.05);(3).Chi-square test of moratily.tumor location (χ2=11.311,P=0.001), tumor size (χ2==4.304,P=0.049),tumor invasiveness (χ2=3.874,P=0.091),vessels and nerves wrap around (χ2=10.836,P=0.005),tumor margin (χ2=1.308,P=0.375),tumor shape (χ2=0.420,P=0.500),degree of tumor enhancement (χ2=0.209,P=1.000),peritumoral edema (χ2=0.529,P=0.529),differences of tumor location,tumor size,vessels and nerves around were statistical significance (P<0.05). 2. Results of Binary Logistic stepwise regression analysis(1).Tumor location, tumor size, tumor invasiveness, tumor shape, tumor boundary are five independent risk factors of tumor residual, and tumor invasiveness is the main risk factor.(2).Tumor location, tumor size, vessels and nerves wrap around and tumor enhancement degree are four independent risk factors of surgical complications, and tumor location is the main risk factor of surgical complications.(3)Tumor location, tumor size are two independent risk factors of morbidity, and tumor location is the main risk factor of mortality.(4)Tumor location, tumor size are two independent risk factors of tumor residual, surgical complications and mortality.Conclusion Preoperative image information of meningioma,especially the four main factors including tumor location,tumor size,tumor invasiveness,nerves and vessels wrap around may objectively and accurately to estimate and evaluate meningioma resection degree,surgical complications and mortality.Tumor invasiveness is the most important factor of tumor residual,and tumor location is the most important factor of surgical complications and mortality. Section two Grading of preoperative images and surgical risks assessment in patients with meningiomaObjective To put forward a grading scheme of meningioma to concisely and effectively evaluate and estimate prognosis preoperatively.Methods One hundred and seventy-two (172) patients with complete image information were retrospectively analyzed, of which57male and115female.age range from23to80years,and53years old on average,serious heart disease, pulmonary disease, hepatopathy, nephropathy or endocrine function are excluded preoperatively.Patients were performed with CT plain scan and Contrast enhancement scanning, CTA and (or) conventional MRI scanning, the intravenous paramagnetic contrast agent magnevist injection (GD-DTPA) enhancement scanning (scanning parameters the same as flat T1WI),MRA,MRV,and some patients with DSA examination. Conventional MRI scanning includes the T1-weighted images (T1WI), T2weighted images (T2WI) and fluid attenuation inverse recovery (FLAIR) sequence.1. Clinical dataRecording each patient’s age, gender, preoperative clinical manifestation,image information of head CT and (or) magnetic resonance imaging, the postoperative clinical manifestation,degree of tumor resection,postoperative complications and mortality according to patients’ clinical medical records (admission record, operation notes, postoperative progress notes, preoperative and postoperative image information, laboratory results, etc.) Images information of meningioma includes tumor location, tumor size, tumor invasiveness. vessels and nerves wrap around, peritumoral edema, tumor margin, tumor shape, degree of tumor enhancement in common.2. Evaluation standard(1).Having or not complete resection or have or not residual. According to standard of grade of meningeal tumor resection Simpson proposed in1957:Grade I: Macroscopically complete tumour removal, with excision of its dural attachment and of abnormal bone. Resection of the sinus where tumour arises from the wall of a dural venous sinus.Grade II:Macroscopically complete tumour removal with endothermy coagulation of its dural attachment.Grade III:Macroscopically complete tumour removal without resection of coagulation of its dural attachment or its extradural extension.Grade Ⅳ:Partial tumour removal, leaving intradural tumour in situ, simple decompression, with or without biopsy. Seeing Grade Ⅰ and Grade Ⅱ cases as complete resection, and see Grade Ⅲ, Grade Ⅳ and Grade Ⅴ as residual in this research.(2).With or without surgical complications. One or more complications of every patient including as follow:brain swelling,cerebral hemorrhage,hemiplegia, intracranial infection, high fever, coma, cerebral herniation, hydrocephalus, epilepsy, diabetes insipidus,subcutaneous effusion,cerebral ischemia,cerebrospinal fluid leakage,aphasia,scalp infection,cranial nerve and cerebellar dysfunction (facial paralysis,cough and hoarseness,visual disturbance,dysosmia,hearing disorder, balance disorder, etc.).(3).With or without mortality.3. Statistical analysisUsing SPSS19.0software for statistical analysis.Univariate analysis (chi-square test or Fisher test)was first performed to analyze various factors that influence degree of tumor resection,surgical complications and mortality,P<0.05for difference were statistical significance.Then tumor with or without residue,with or without complications, with or without mortality as dependent variable respectively,factors of statistically significant as independent variable for binary Logistic stepwise regression analysis,and with P<0.1for difference were statistically significance. Chi-square test of linexlist data (P<0.05for the difference was statistical significance) Multiple comparison among multiple sample rates using the chi-square split-run method, with P<0.0125for the difference was statistical significant and spearman correlation analysis were performed in the analysis of meningioma grades and surgical risks assessment4. Screening and determining the main factorsResults of Univariate analysis(1).Differences of tumor location, tumor size, tumor invasiveness, vessels and nerves wrap around, tumor margin, tumor shape and degree of tumor enhancement were statistical significance in tumor residual (P<0.05).(2).Differences of tumor location, tumor size, vessels and nerves wrap around, tumor shape and degree of tumor enhancement were statistical significance in surgical complications (P<0.05).(3).Differences of tumor location, tumor size, vessels and nerves around were statistical significance in mortality (P<0.05).Results of Binary Logistic stepwise regression analysis(1)Tumor location and tumor size are two independent risk factors of tumor residual, surgical complications and mortality.(2)Tumor invasiveness and tumor location are the main risk factors of tumor residual.(3)Tumor location and nerves and vessels wrap around are the main risk factors of surgical complications.(4)Tumor location is the main risk factor of mortality. So tumor location, tumor size, tumor invasiveness, vessels and nerves wrap around are the four main factors that can objectively evaluate and judge degree of tumor resection, surgical complications and mortality of each meningioma surgery.5. Voluation and grading schemeChoosing the four major influence factors including tumor location, tumor size, tumor invasiveness, nerves and vessels wrap around as grading index.Tumor location was divided into:Group of not skull base (0points),Group of skull base (2points).Tumor size was divided into:Group of tumor maximum diameter d≤5cm (0score),Group of maximum diameter d>5cm (1points). Tumor invasiveness was divided into:Group of no invasiveness (0points). Group of having invasiveness (2points). Nerves and vessels wrap around was divided into:Group of no around (0points); Group of having around (1points).Meningioma was divided into grade: grade Ⅰ(0～2points), grade Ⅱ(3～4points) and gradelll (5～6points) according to the total score of each meningioma patients (total score=tumor location+tumor size+tumor invasiveness+vessels and nerves wrap around),and then meningioma grade was retested by degree of tumor resection, surgical complications and mortality.Results1. Results of chi-square test of linexlist data:(1).Differences of tumor residual among different grades of meningioma were statistical significance (P<0.05).(2)Differences of surgical complications among different grades of meningioma were statistical significance (P<0.05).(3)Difference of mortality among different grades of meningioma were statistical significance (P<0.05).2. Results of multiple comparison among multiple sample rates:differences of tumor residual rate, surgical complications rate and mortality were statistically significant (P<0.0125).3. Results of spearman correlation analysis:(1) Grades of meningioma associated with rate of tumor residual (r=0.537,P<0.000);(2) Grades of meningioma associated with rate of surgical complications(r=0.385, P<0.000);(3) Grades of meningioma associated with rate of mortality(r=0.254, P<0.000). Grades of meningioma was positive correlated with tumor residual rate, complication rate and mortality rate are positively (r>0) Conclusion The higher the grade of meningioma, the lower rate of tumor total resection (the higher rate of residual), rate of surgical complications and mortality also had certain relation with meningioma grades.This method of meningioma grading has certain clinical significance for preoperative assessment of meningioma surgery.